Give Your Revenue Cycle a Boost Techniques to Improve Collections for Your Physician Practices

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1 Give Your Revenue Cycle a Boost Techniques to Improve for Your Physician Practices Presented by: Alta Partners, LLC Stan Kasmarcak Susannah Selnick Lacy Sharratt June 8, Ohio Hospital Association Annual Meeting

2 Give Your Revenue Cycle a Boost! & financial analysis collection procedures programs Payer Relations & On-going Monitoring & Control Front-end procedures coding & documentation Timely charge, claim submission Agenda 1. Introductions 2. Tips to Improve each piece of your Physician Practice Revenue Cycle: 1. Front End 2. Claims Management 3. Financial Reporting and Feedback for Improvements 3. Open Q&A internal controls

3 Patient Scheduling Goal Action(s) Helpful Hints Fill every appointment spot for every schedule Schedule an appointment for every patient encounter Offer unused spots in upcoming schedules first Work the appointment wait list to fill empty spots Confirm appointments on upcoming schedule Identify patterns of no-show and cancellation rates Look for practice scheduling patterns Track and record all add-on encounters Include inpatient, radiology & lab, Emergency Department, and OR encounters in scheduling Make sure to fill end-of-day and lunch time appointments Call patients 1-2 days prior to appointment Use selective double booking at peak no-show/ cancellation times Make sure to fill end-of-day and lunch time appointments Use a software or mobile program for providers to add on encounters at any time

4 Patient Registration Goal Action(s) Helpful Hints Collect complete and accurate information Verify insurance for all patients prior to appointment Gather as much information as possible at time of scheduling Remind to bring ID and Insurance card to appointment Build mandatory data fields Check for changes to existing information Run batch insurance verification prior to appointments 2 days prior to schedule Run insurance verification for add-on patients Ad-hoc upon scheduling Call patients with rejected insurance & update information Inform if no insurance at TOS, will be self-pay

5 Insurance Verification Prior Insurance Verification: 2/7/15 for DOS 2/9/15 Policy Status Practice A Percent of Total Eligible 72% Eligible Other 1% Inactive 1% Insurance-Related Denials for DOS 2/9/15 Practice A Prior Insurance Verification Practice B No Prior Insurance Verification Denial Description % Total Denials % Total Denials INS TERMINATED - 14% Invalid Request 13% Not Found 13%

6 Patient Check-In/ Check-Out Goal Action(s) Helpful Hints Maintain complete and accurate patient information Collect co-pays at TOS Collect account balances at time of service Schedule all follow-up appointments at check-out Include in front-desk staff job protocol: verify and update all demographic, contact, and insurance information upon check-in Ask every patient for copay upon check-in and remind patient at appointment reminder call Notify all patients of account balances upon appointment scheduling and offer to process payment at time of check-in Notify self-pay patients of any discounts for paying in advance Include in front-desk staff job protocol: stop every patient at check-out to schedule any follow-up or routine appointments Manage patient return mail for incorrect contact information, and rejected claims for incorrect insurance information Build mandatory data fields Accept cash, check, and credit card for ease of collection Accept cash, check, and credit card for ease of collection Discount services for patients paying cash at time of service Give patients reminder cards for follow-up appointment Every patient needs to stop for clinical summary

7 Patient Financial Policies Financial policies should be written, posted, and available upon request Goal Action(s) Helpful Hints Co-Pay Policy Self-Pay Policy Charity Care Policy Inform patients that all copays must be collected at time of service Set fee schedule for self-pay patients and notify upon scheduling and time of appointment reminder Establish a self-pay discount for patients paying cash at time of service Notify patients of hospital charity care policy Remind patients of copay at time of scheduling and in appointment reminder Example: $100 New Patient, $60 Established Patient, $200 Procedure to be collected prior to appointment Example: 30% discount for paying cash in-full at TOS Provide instructions on how to apply for hospital charity care

8 Coding & E/M Coding Audit Surgical/ Procedural Coding Audit Variability in codes Will check for degrees of accuracy Codes are either right or wrong Will look at appropriate modifier usage and number of units How to ensure accurate coding and documentation: Use a certified professional coder to review physician records and billing In-house or Outsourced Educate providers on proper documentation techniques Schedule routine chart audits to ensure providers are meeting compliance expectations

9 Coding & Example E/M Coding Audit Results Total Charts Correct Over Under Miscode Group A Group B Group C Total 1, Miscodes are a result of a billing system error. Ex: no code entered, new patient coded as established (and vice versa) 67% 20% 8% 6% Payers will request a takeback for over-coded claims Missing revenue from under-coded claims

10 Coding & Creating a Meaningful Chart Audit Program Establish target coding accuracy 80% 90% Measure on a routine schedule Annually Select appropriate sample charts / provider 5 New & 10 Established patients E/M vs. Procedure codes Identify underlying issues Inaccurate coding (coding staff) Improper documentation (providers) EHR configuration Create follow-up plan for improvement Provider education Coding Staff education Optimize EHR templates & workflow Accountability for Improvement

11 and Claim Goal Action Helpful Tips Submit all encounter forms in a completed state, or sign all EHR encounter notes and assign all encounters with CPT codes Respond timely to all inquiries regarding incomplete encounter forms/ unsigned notes Submit charges for every patient encounter Assign a staff member responsible for checking for completeness Establish a formal protocol of communicating incompleteness and receiving responses Assign a staff member to reconcile missing charges to schedules and censuses Reconcile daily Depending on practice workflow, can be MA, front desk, office manager, secretary Use E/M calculator in EHR Charges should be submitted within 2 business days of service Communicate incomplete forms or unsigned note statuses daily Reconcile missing charges daily Can assign to secretary, charge entry coordinator, practice/ office manager Enter charges timely to reduce charge lag and reimbursement delays Establish a formal deadline for submitting and reconciling all charges By the end of each month, all charges for that month should be reconciled

12 and Claim To Schedules Within EHR All scheduled appointments have a charge entered & all charges entered have a scheduled appointment All appointments have notes & notes have appointments Use Practice Management software for missing charge report % notes closed within 48 hours % successful pass from EHR to PM software Audit log - user and activity Use Cosign/ Ready for Review function before passing charges

13 Thorough Prep Work Front End Accuracy, Completeness Accuracy, Compliance Timely Filing Completeness, Reduction of Errors I/T Manage Authorization Who has access to adjust account information Ex: Front desk enters charges, back office posts payments Master File Check for unusual entries - negative cash payments, positive denials, etc Review Master Files for inappropriate information Strong Cash Management Make a daily deposit that ties to the day end charge / cash reports and go to bank with five daily deposits each week Use bank deposit locator slips to help reconcile your daily PM system entries to bank Beware of the overly dedicated or defensive employee!

14 Accounts Receivable Management Paid: Use and Financial (back end) to evaluate if payments are made at contracted rates for the services rendered Denials: Unpaid claims need to be analyzed by volume and worked on collaboratively (revenue cycle and practice operations) so that they can be eliminated Success in A/R is achieved when doing less work rather than more by being an advocate / advisor to the front office entry personnel These three reasons for Denials account for over 85% of all denials 1. Registration Errors: patient demographic and payer specific 2. Coding Errors: Educate staff and providers on better coding and eliminating bad coding from the beginning 3. Claim Timeliness: Provide feedback to practice management to ensure that claims are not waiting to be worked

15 Collection Accounts Receivable Management % of First Claims Rejections Charge Lag Days Revenue Outstanding (DRO) % of Denials Less than 5% of all claims submitted Assumes insurance verification performed by DOS Office Practice: 2 days or less Surgical/ Hospital Practice: 6 days or less Feb- April 50 days or less Patient deductibles reset at beginning of year May January 45 days or less Office Practice - <2.0% Surgical Practice - <4.0% Coding rules that vary among payers will cause a slightly higher denial rate % of Bad Debt 2.0% or less if managed aggressively

16 Accounts Receivable Management This simple report can show a great deal about the current state of your practice s A/R Charges Payments Adjustments Balance Total WRVU 2014 No charge $ - $ (12,985) $ 13,719 $ 1, No pymt; bal due $ 807,508 $ - $ (100,642) $ 706,746 7,666 No pymt; no bal $ 304,705 $ (109) $ (304,428) $ 129 2,463 Pymt rec'd; bal due $ 1,625,953 $ (779,404) $ (662,530) $ 186,943 15,538 Pymt rec'd; no bal $ 16,862,289 $ (9,618,462) $ (7,290,620) $ - 144, Total $ 19,600,456 $ (10,410,961) $ (8,344,501) $ 895, , No charge $ - $ (2,468) $ 5,768 $ 3, No pymt; bal due $ 720,374 $ - $ (96,056) $ 624,144 5,982 No pymt; no bal $ 61,054 $ - $ (61,038) $ Pymt rec'd; bal due $ 806,472 $ (360,309) $ (308,464) $ 137,784 7,684 Pymt rec'd; no bal $ 4,295,051 $ (2,381,474) $ (1,918,872) $ - 35,166

17 Understand the Source of Your Denials Service Type Charge Denied % Surgery Services $1,315,194 45% Radiology Services 429,439 15% Established Patient 332,947 11% New Patient 71,028 2% Preventative Medicine Est. 13,536 0% Preventative Medicine New 5,930 0% Hospital Inpatient 211,337 7% Medicine Services 139,451 5% Consultation Services 7,797 0% Psychiatry Services 7,369 0% % by Service Area 60% 15% 13% Supplies 142,215 5% 5% Home Services New & Est 68,259 2% Nursing Facility Services 50,750 2% Total Denied $2,903, % 100% Total Charges for Year $99,228, % 4% Surgical denials likely due to coding errors Registration Errors Registration and Coding Errors Coding Errors Registration Errors

18 Denial Management in terms of wrvu s Compensation/ wrvu: Are you netting your denial wrvu s from your provider s production? Summary of Denials by wrvu Office Visits Hospital Visits Other Visits Medicine Radiology Surgery Grand Total Bad Insurance 15,471 7,798 6,331 5,710 5,640 8,083 49,032 Global Procedure , ,801 8,213 Benefit Max 1,390 1, ,985 Timely Filing 1, ,515 Patient info requested by Ins ,816 Coordination of Benefits ,429 Appeal Denied ,024 1,255 Pending Additional Medical Info ,063 21,238 10,741 7,569 7,206 6,439 17,114 70,308 Est Reimb / WRVU $ 73 $ 50 $ 73 $ 50 $ 60 $ 60 Lost Revenue $ 1,550,402 $ 537,075 $ 552,563 $ 360,286 $ 386,365 $ 1,026,844 $ 4,413,535 Est Compensation / WRVU $ 35 $ 50 $ 35 $ 35 $ 35 $ 60 Potential Add'l Physician Comp $ 743,344 $ 537,075 $ 264,927 $ 252,200 $ 225,380 $ 1,026,844 $ 3,102,865

19 Factors to Consider When Performing Financial Site of service RHC vs Non-RHC Facility vs Non-facility Provider type Physicians Nurse practitioners Physician assistants Government programs Practice specific circumstances PQRS Meaningful Use Sequestration Patient demographics Provider FTEs Seasonality Payer mix Procedure mix Commonly used as a quick reference tool Provides insight into business operations Scoreboards Helps to track effectiveness of initiatives Allows for early identification of potential issues

20 Production Summary: provides an overview of practice revenues (charges & payments) and production (Work RVU s & Visits) Two year historical trend makes it easy to identify month-to-month trends, variances or sudden changes Monthly averages allow for quick comparison to previous year to see if levels are similar Work RVU and Visit summaries can be used to quickly understand production levels

21 Payer analysis: provides a breakout of various measures by payer Understanding payer mix is important because it affects revenues, given that each payer reimburses differently The breakdown of denial percentage by payer allows you to quickly see which payer(s) has the highest denial rate; from there, you can examine more closely to identify the source of the problem It also provides snapshot of total denials; 2% is ideal, anything higher should be flagged for further review The payer analysis section also shows what the charges and payments for each payer are as a percent of Medicare. If payments are low, there may be issues such as low contract rates or not receiving full payments from the insurer Accounts Receivable (A/R) : provides a breakout of A/R metrics by payer Helps you to understand your accounts receivable including who the responsible party is (insurance vs patient) The AR % of Total columns shows how much of your total A/R balance con be attribute to the different payers; if a payer suddenly makes up a larger percent of your total A/R, may indicate underlying issues that need to be addressed The AR % Over 90 Days is an important statistic to determine how effective your practice is at collecting payments for service Allows you to find red flags that may indicate difficult in collecting from a particular payer

22 Monthly Activity: provides a more detailed look at charges and payments Charge errors should be minimal and relatively stable If they are high or there is an increasing trend, it would be beneficial to meet with staff to resolve the issue There are various adjustments made to claims; denial adjustments are important to watch If denials are high or show an increasing trend, you should review the primary denial codes and work with staff to (1) clean-up current denied claims and (2) determine changes that could help prevent denials in the future DRO (Days Revenue Outstanding) shows how effective your practice is at collecting revenues Patient Coding Profile: uses graphs to compare E&M coding pattern to averages within Alta Partners database for that specialty This does not determine appropriateness of coding, that can only be determined through a coding audit. Coding patterns may vary due to reasons such as patient demographics and provider preference.

23 Other Statistics: provides a snapshot of additional metrics used to evaluate performance Average WRVU per visit shows the level of work being performed for each visit; this statistic is important because it is tied to reimbursement The Medicare allowable rate is determined based on RVU values, including WRVU s. The higher the WRVU per visit, the higher the expected payment per visit The denial summary shows top denial codes If denials are high, this summary can be used to identify which denial code to address first (correct and resubmit claims, if possible) This can also be used to identify which denial codes are consistently a problem; can further review to determine the underlying process issues contributing to the denials then work with staff member to develop a plan to reduce these errors

24 Ensure staff members understand their role in the revenue cycle Verify staff has been trained properly on the practice s policies and procedures Educate staff on government programs that affect the practice and its revenues, including PQRS, Meaningful Use and the Medicare Access & CHIP Reauthorization Act (MACRA) Establish a structured plan to communicate with staff Encourage continuing education Promote cross-departmental knowledge for staff to understand each other s roles & why each is done

25 Conclusions Q & A Communication between all parties involved with the revenue cycle is key. Stan Kasmarcak (440) Susannah Selnick (440) Lacy Sharratt (440)

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